course for elderly
Haringsma, R.
Citation
Haringsma, R. (2008, January 31). Never too old to learn : the effectiveness of the Coping with Depression course for elderly. Retrieved from https://hdl.handle.net/1887/12620
Version: Not Applicable (or Unknown)
License: Licence agreement concerning inclusion of doctoral thesis in the Institutional Repository of the University of Leiden
Downloaded from: https://hdl.handle.net/1887/12620
Note: To cite this publication please use the final published version (if applicable).
Never too old to learn
The effectiveness of the Coping with Depression course
for elderly
Haringsma, Rimke
Never too old to learn. Effectiveness of the Coping with Depression course for elderly
Thesis Leiden University - With summary in Dutch ISBN 978-90-8891-0272
Cover design: Carin Althuizen: althuizen@fishtwins.nl
The study was supported by the Netherlands Organisation for Health Research and Development (Zorg Onderzoek Nederland, ZonMw), Grant 98-04-56.
No part of this book may be reproduced in any form by print, photoprint, microfilm or any other means without written permission from the author
Never too old to learn
The effectiveness of the Coping with Depression course for elderly
Proefschrift Ter verkrijging van
de graad van Doctor aan de Universiteit Leiden, op gezag van Rector Magnificus prof. mr. P.F. van der Heijden,
volgens besluit van het College voor Promoties te verdedigen op donderdag 31 januari 2008
klokke 15:00 uur door Rimke Haringsma geboren te Djakarta, Indonesië
in 1951
Promotor:
Co-promotor:
Prof. dr. Ph. Spinhoven Dr. G.I. Engels
Referent: Prof. dr. R.C. van der Mast Universiteit Leiden – LUMC Overige leden: Prof. dr. A.T.F. Beekman,
Vrije Universiteit Amsterdam - VUMC Prof. dr. P. Cuijpers,
Vrije Universiteit Amsterdam Prof. dr. A. J.W. van der Does
Content
Chapter 1 General Introduction 1. Depression in elderly 1.1 Diagnosis
1.2 Course of depression in elderly 1.3 Risk factors
1.4 Prevalence 2. Interventions 2.1 Treatment 2.2 Prevention
3.‘Coping With Depression’ course for elderly 4. Outline
7
Chapter 2 The criterion validity of the Center for Epidemiological Studies Depression Scale (CES-D) in a sample of self- referred elders with depressive symptomatology
25
Chapter 3 Effectiveness of the Coping With Depression Course for Older Adults provided by the community-based mental health care system in the Netherlands; a randomized controlled field trial
37
Chapter 4 Predictors of response to the Coping With Depression Course for Older Adults. A field study
57
Chapter 5 Effects of depressed mood on autobiographical memory in older adults with and without lifetime depression
81
Chapter 6 General Discussion 1. Results
1.1 Characteristics of the participants 1.2 Study 1: Criterion validity of the CES-D 1.3 Predictors of outcome
1.4 Specificity of Autobiographical Memory 2. Discussion of the results
2.1 Prevention 2.2 Treatment
3. Could the course be more effective?
4. Limitations and Strengths 4.1 Limitations
4.2 Strengths
99
6. Future directions 6.1 Age
6.2 Education and lower social economic status 6.1 Ethnicity
Summary 125
Samenvatting 131
Dankwoord 137
Curriculum vitae 141
1
General introduction
General Introduction
9
General Introduction
This thesis evaluates a group intervention developed for the prevention and treatment of late life depression. In this time and age many adults will have had some experience with depression, either by knowing a relative, friend or colleague who was depressed, or by having lived through it themselves. Although the public is relatively well informed about depression, many still find it hard to understand how debilitating a depressive episode is. Being disabled because of a physical ailment (a broken leg or pneumonia) might be much easier to comprehend and doesn’t seem to imply a personal weakness. This is especially true for the older generation, who grew up when less was known about depression. Effective pharmacological and psychological treatments have been developed to ease the burden of an acute depressive episode.
Over the years treatment-seeking rates have been increased, especially for the middle- to-older adult and the young elderly (Bristow & Patten, 2002). However, in a longitudinal community study in the Netherlands, Beekman, Deeg, Braam, Smit and van Tilburg (1997) found that elders with major or minor depression were not adequately treated despite the fact that they were seen regularly by their general practitioner (GP). Antidepressants and community mental health services were underused, whereas medical health services were excessively used (Beekman et al., 1997).
The likely reason is that the symptoms are not recognized for what they are by the depressive elderly person him/herself or by his/her family or medical professionals. Symptoms such as memory loss and impaired executive functioning are seen as part of the normal aging process or beginning dementia. Feelings of sadness and lack of enjoyment are labelled as grief; grief over loss of physical faculties, loss of partner, loss of peers. Furthermore, the older elderly grew up in a time when depression as such was not recognised and one was urged not to give in to a negative mood. They may not insist on being treated for their feelings of misery.
In this chapter, section 1 will deal with depression, its course, risk factors and prevalence in the elderly; section 2 will focus on curative and preventive interventions in the elderly. Because the subject of this research project was the effectiveness of the Coping With Depression (CWD) course as it is provided by the community mental health care system in the Netherlands, section 3 will describe in more detail the CWD course and the common practice of the prevention departments of the Dutch community mental health centres (CMHCs) in recruiting and enrolling participants than is done in chapters 3 and 4, which concern the effectiveness of the CWD course and the predictors of treatment outcome. The chapter ends with an outline of the chapters of this thesis.
1. Depression in the elderly 1.1 Diagnosis
Depression is a serious mental illness which lasts for at least two weeks and is characterised by a profound sad mood and lack of enjoyment (anhedonia) (American
10
Psychiatric Association, 1994). Apart from these core characteristics, a depressed patient suffers from a range of cognitive, behavioral and somatic complaints (see table 1). A distinction is made between major depression and subthreshold, minor or subclinical depression when high levels of depressive symptoms are reported, but not all criteria for diagnosis of major depressive disorder (MDD) according to the diagnostic and statistical manual of mental disorders – 4th edition (DSM-IV; APA, 1994) are met.
It is generally thought that subthreshold depression (SD) is more prevalent in primary care and community populations, whereas MDD is found more in the specialty mental health sector (Pincus, Davis & McQueen, 1999). A problem is the great variation in criteria sets used to diagnose these so-called ‘minor forms’, with the result that prevalence rates vary greatly depending on the set used. The criteria sets used by most authors include the two core symptoms sadness and anhedonia and a clinical criterion stating that it causes clinically significant distress or impairment in social, occupational or other important areas of functioning (Pincus et al., 1999).
DSM-IV includes Minor Depression under the Depressive Disorder not otherwise specified (NOS). Minor Depression is diagnosed when at least two but less than five depressive symptoms are present during a two week period, with no history of a major depressive or manic episode or Dysthymia, which precludes intermingling with an incomplete recovery from a major depressive episode. Dysthymia is another DSM-IV disorder often considered to be a form of minor depression. Dysthymia differs from MDD in the severity and duration of the symptoms. The sad mood is present most of the time and has been present during at least two years. Other diagnoses are based on the severity of the symptoms and the use of screening questionnaires (Feldman, Robins & Jaffe, 1998). Well-known are the Beck Depression Inventory (Beck, Ward, Mendelson, Mock & Erbaugh, 1961), the Hamilton Rating Scales for Depression and Anxiety (Hamilton, 1967) and the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff 1977). The latter was used in the research reported in this thesis. The number of symptoms reported during the previous week is summed; a sum score above 15 is an indication of a clinically relevant depression in the general population (Radloff, 1977; Beekman et al. (1997a).
Large studies like the Medical Outcomes Study (MOS; Wells et al., 1989), and in the Netherlands the Groningen Longitudinal Aging Study (GLAS; Ormel et al., 1998), showed that the impact of MDD or subthreshold depression (SD) on the quality of life was greater (more dysfunction, poorer health perception and well-being) than that of chronic medical conditions like heart-lung diseases, coronary conditions, diabetes, and hypertension (Ormel et al, 1998). Furthermore, depression is considered an independent risk factor for the onset of cardiovascular diseases (CVD) (Fraser-Smith
& Lespérance, 2006; Kooy, et al., 2007). In patients with established CVD, depression increases the risk of mortality and cardiac events (Fraser-Smith & Lespérance, 2006).
General Introduction
11 Table 1. Major Depressive Disorder and Dysthymia according to DSM-IV
Major Depression Dysthymia
Core symptoms Depressed mood
Loss of interest (anhedonia)
Depressed mood
Additional symptoms
Changes in weight or appetite Change in sleep pattern
Psychomotor agitation or retardation Loss of energy
Feelings of guilt or worthlessness Loss of concentration/indecisiveness
Thoughts of death, suicidality
Appetite change Change in sleep pattern
Loss of energy
Feelings of worthlessness
Loss of concentration/indecisiveness Feelings of hopelessness
Time criteria Continuity
Duration
Most of the day Every day At least 2 weeks
Most of the day Most days Two years Symptom score Both core symptoms + 3 additional
symptoms
One core symptoms + 4 additional symptoms
Core symptom + 2 additional symptoms
Apathy, which is part of the depression syndrome, can be an early sign of dementia in the elderly (Onyike et al., 2007). However, it is also considered a distinct syndrome, (Marin, Butters, Mulsant, Pollock & Reynolds, 2003) with its own pathogenesis, treatment and prognosis, in non-demented elderly (Vinkers, van der Mast, Stek, Westendorp & Gussekloo, 2006). Feil, Razani Boone and Lesser (2003) found that apathy was related to executive functioning in non-demented older depressed individuals.
1.2 Course of depression
The onset of the first depressive episode can happen at any age from childhood to old age, but the common age of onset lies before age 30 (Burke, Burke, Regier & Rae, 1990). Depending on the study depression is defined as late onset depression when the first episode occurs after the age of 55, 60 or 65. In a large representative sample of community-living elderly aged between 65 and 84 of the Amsterdam Study on the Elderly Amsterdam Study of the Elderly (AMSTEL; van Ojen, Hooijer, Lindeboom &
van Tilburg, 1995), 31% reported the first onset between 50 and 65 and 14% reported the onset after 65. Results from clinical studies comparing early onset depression
12
(EOD) with late onset depression (LOD) have suggested that EOD is associated more with genetic vulnerability and personality disorder, whereas vascular diseases and white matter lesions in the brain are implicated in LOD (Ernst, 1997; Murata et al., 2001). Recent prospective studies argue against the so-called vascular depression hypothesis. Generalized atherosclerosis precedes cognitive decline, but not depression (Vinkers et al., 2005).
Symptoms can differ by age and by age of onset. In a study of lifetime symptomatology of depression in the elderly, Heun, Kockler, and Papassotiropoulos (2000) found that loss of interest, thought disorder and tiredness were more characteristic for the younger elderly, but did not depend on age of onset. Low spirits and feelings of worthlessness are more frequent in EOD, but did not depend on age.
However, in a recent community-based study in an aging population in the Netherlands no clear differences were found in etiology and phenomenology between early and late onset depression (Janssen, Beekman, Comijs, Deeg & Heeren, 2006). In a prospective population-based study of the very old, the Leiden 85-Plus study, no relationship was found between depression and vascular diseases either (Vinkers et al., 2005).
Longitudinal research has shown that depression is a recurrent disease in which acute depressive episodes are followed by periods of complete or partial recovery (Judd et al, 1999; Mueller et al, 1999). The mean duration of a depressive episode is between four and six months and most people (87%) recover without treatment within two years (Coryell et al., 1994). This leaves a substantial minority of 15% for whom the depression is chronic as defined by DSM-IV, i.e., lasting more than two years. The chance of the recurrence of a new depressive episode is high too. Mueller et al. (1999) conducted a 15- year observational follow- up study and found that 85% of the 380 subjects had a new depressive episode within 15 years of follow- up. The mean time to a recurrence was 145 weeks (SD = 160). The individual rate of recurrence increases with the number of episodes (Kessing, Hansen, Andersen, & Angst, 2004), and Kruijshaar et al. (2005) have estimated that the mean life time prevalence is around 7- 8 episodes. In late life remission rates hardly differ from those in mid-life depression, but relapse rates appear to be higher in older persons (Mitchell & Subramanaim, 2005). In other words, depression can often be considered a lifelong condition.
1.3 Risk factors
A wide range of socio-demographic, psychosocial and illness-related variables have been identified as risk factors for incidence, severity, course and remittance of depression. The most striking is the gender difference: epidemiological community surveys have shown that women suffer twice as often as men from depression (Blazer, Kessler, McGonagle, & Swartz, 1994; Weissman & Olfson, 1995). This difference in prevalence remains in old age, although it becomes less pronounced (Stek, Gussekloo, Beekman, van Tilburg, & Westendorp, 2004).
General Introduction
13 Reviewing the literature on risk factors for depression among community living seniors Cole and Dendukuri (2003) concluded that bereavement, sleep disturbance, disability, prior depression, and female gender were significant risk factors for the incidence of depression. Risk factors for the first episode differ from those for recurrent episodes. Major negative life events are associated with first episodes (Kessler, 1997) regardless of age of onset (Schoevers et al., 2000). Residual symptoms and the number of previous episodes are the greatest risk factors for a recurrence (Judd et al., 1998; Kessler, 1997). Gender specific risk factors were found in the AMSTEL study (Schoevers et al., 2003). In women a personal history of depression and functional disability (activities of daily living) were risk factors for relapse or chronicity, while in men these were loss of spouse and instrumental disability (i.e.
instrumental activities of daily living). In older adults, Beekman et al. (1995) compared risk patterns for minor and major depression. They concluded that a history of previous episodes is the largest risk factor for major depression, while minor depression seemed more of a reaction to life stress common to aging, particularly deteriorating physical health (Beekman et al., 1997b). Debate is going on whether SD and MDD are placed on a continuum, or that underneath the similar phenomenological expression lay different mechanisms (Geiselmann & Bauer, 2000). It has been well- demonstrated that untreated subclinical depression is a risk factor for a MDD a year later, especially if it is coupled with a negative life event (Beekman et al., 1995).
Whether age itself is a vulnerability factor is not clear. Schoevers et al. (2000) concluded that the effect of age disappeared when other potentially relevant factors were controlled for. On the other hand, Rothermund and Brandstädter (2003) found in their longitudinal study assessing depression symptoms in six age cohorts that from the age of 66, both men and women report more depressive symptoms.
Depression and cognitive decline are highly correlated. In the Leiden 85-Plus study, a prospective population-based study of the very old, generalized atherosclerosis was related especially with memory loss. In this prospective study it was found that depression followed cognitive decline, but did not predict cognitive decline (Vinkers, Gussekloo, Stek, Westendorp &, van der Mast, 2004). Poor daily functioning and institutionalisation were significant characteristics for the incidence of depression in the very old. Just as in the younger old the remission rates were poor and relapse rates were high (Stek et al., 2006).
Another category of prognostic factors is formed by cognitive vulnerability markers. One of these is autobiographical memory specificity (AMS), which is the ability to remember personal events with contextual detail (Tulving, 2000).
Autobiographic memory is part of the episodic memory system (Tulving, 2000). The Autobiographical Memory Test (AMT; Williams & Broadbent, 1986) is a task used to measure it. Studies comparing younger depressed adults with healthy adults showed that the former did significantly worse on recalling specific memories (Brittlebank, 1983; van Vreeswijk & de Wilde 2002; Williams, 1996). It was found that these patterns persisted once a patient had remitted (Mackinger, Pachinger, Leibetseder, &
14
Fartacek, 2000; Nandrino, Pezard, Poste, Reveillere, & Beaune, 2002; Park, Goodyer,
& Teasdale, 2002; Spinhoven et al., 2006; Williams, 1996). These findings suggest AMS is not mood- state dependent but an enduring characteristic of people with lifetime depression. AMS showed prognostic properties by predicting the persistence of an acute depression. However, it did not predict relapse/recurrence in a sample of remitted mid- life adults (Spinhoven et al., 2006). Whether AMS as measured with the AMT is a possible marker for depression vulnerability in older adults has been described in chapter 5.
1.4 Prevalence
Depression is widely prevalent in the adult population; in the National Comorbidity Survey the prevalence estimate for current major depression was 4.9% and for lifetime major depression was 17% (Blazer et al., 1994). These rates may be biased by recall problems. In a recent study, an indirect estimation method was used to estimate lifetime prevalence in Australia and the Netherlands. For both countries the model estimated that the lowest proportion of cases was much higher: 30% for men and 40%
for women (Kruijshaar et al, 2005).
In the elderly prevalence of major depression is much less, namely around 3%.
But when less rigorous diagnostic criteria are used, 8 – 15% suffers from subclinical or minor depression (Beekman, 1995; Beekman, Copeland & Prince, 1999; Blazer 1987;
Karel & Hinrichsen, 2000). In our rapidly aging population the absolute number of cases will become a large burden for the mental health care system. In 2007 for instance, 2,348,243 Dutch citizens (14.4% of the total population) will be over 65 years, and in 2017 this number will have risen to 3,002,165 (18% of the total population) (statistics from Central Bureau for Statistics, 2007). By that time the number of elderly individuals that need treatment for major and minor depression will have increased 28% (375,713 in 2007 versus 480,336 in 2017). These figures underscore the importance of prevention of depression, not only for the elderly but for the whole population.
2. Interventions
Interventions can be either curative or preventive. Although prevention is better than cure, many people have to be ill before they seek treatment.
2.1 Treatment of acute depression
Psychopharmacological (antidepressants) and psychological treatments have proved to reduce depression substantially in younger adults and are now well accepted. In older adults they are effective too. A systematic review of the efficacy of antidepressants for elderly of 55 and older suffering from major depression showed that antidepressants were more effective than placebo (Wilson, Mottram, Sivanranthan, Nightingale, 2001). In this review, no distinction was made between the young-old (55 – 75) and older-old (≥ 75), who typically have a high prevalence of medical co-morbidity.
Studies of the efficacy of antidepressants in the very old are inconclusive. Gildengers
General Introduction
15 et al. (2002) compared the older-old to middle-old and younger-old. They found that older-old patients responded as quickly and successfully as the young- and middle-old.
However, in a recent study of the efficacy of antidepressants in the older-old, medication was not more effective than placebo (Roose et al., 2004).
In several different meta-analyses and reviews on the efficacy of psychological treatments the conclusion was drawn that successful treatment of major depression does not depend on age (Arean & Cook, 2002; Bartels et al., 2002; Engels & Vermey, 1997; McCusker et al, 1998). However, in these reviews no distinction is made between young-old and old-old either. Arean and Cook (2002) concluded that psychotherapy treatments were acutely efficacious in treating major depression in the older ambulatory person, but that more research is needed on the efficacy of such treatments in the frail elderly. In their meta-analysis of the efficacy of treatments of geriatric depression Bartels et al. (2002) found support for the effectiveness of antidepressants and psychosocial treatment - especially cognitive therapy, behaviour therapy, or the combination cognitive behaviour therapy (CBT) - in the treatment of major depression. Response rates to antidepressants and psychological treatment were similar. The efficacy of combined treatment compared to single therapy (pharmacotherapy or psychotherapy) was associated with a small improvement in efficacy.
Chronically ill or severely depressed patients seemed to benefit the most from adding psychotherapy to antidepressant medication (Friedman et al., 2004). The evidence base for the treatment of subtreshhold depression (SD) is much smaller.
Formulating guidelines for late-life depression Baldwin et al. (2003) concluded that there is no evidence that antidepressants were effective in SD, but there was some evidence that ‘waiting and seeing’ and offering structured support to patient and care- giver were effective.
2.2 Prevention of depression
Prevention is described as ‘to stop something from happening’ (Longman dictionary of contemporary English, 1988). The old system proposed in 1957 by the Commission on Chronic Illness Prevention consisted of three types: primary prevention aimed at decreasing the number of new cases (incidence). The aim of secondary prevention was lowering the number of established cases (prevalence) and tertiary prevention focused on decreasing the amount of disability associated with an existing disorder. In this classification system only primary prevention seems to fit the Longman definition of prevention. Secondary prevention corresponds with treatment and tertiary prevention with maintenance care. Currently the term prevention is reserved for what used to fall under primary prevention. It is divided into three categories (Mrazek and Haggerty, 1994):
Universal prevention when it is a measure for the general public or all members of specific groups (pregnant women, elderly, teenage girls). The measures have an educational character.
16
Selective prevention aims at people at risk for developing a mental disorder, but who are at the time (mentally) perfectly well. Risk can pertain to biological, psychological or social factors which are related to the disorder. In this study: older people with lifetime depression, but who are currently well. Widowhood or physical illness adds to the older person’s vulnerability for depression.
Indicated prevention is meant for high-risk individuals who show minimal but detectable signs of illness; however the DSM criteria are not met. Elderly with subthreshold depression would be candidates.
3. ‘Coping With Depression’ course for the elderly
Effective low threshold interventions have been developed to reach the therapy-shy. In 1984, Lewinsohn et al. (1984) created the Coping With Depression (CWD) course for adults with major depression. Since then this psycho-educational course has been adapted for different populations (for instance adolescents, middle-aged adults, elders, and chronically ill patients) and implemented in the mental health care system in different countries (Germany, The Netherlands, USA). In the Netherlands it has successfully been implemented in mental health care systems that cater to different groups. For instance, all colleges offer the course to students, and the prevention arm of the mental health care system provides the course for middle-aged adults and older adults. A meta-analyses of outreach programs for depressed elderly showed that this type of intervention had a medium-sized effect (Cuijpers, 1998c).
The majority of the prevention departments of the community mental health centres (CMHCs) offer the course twice a year to older persons. The course is a group intervention of 10 sessions lasting two hours and a booster session, two months after the course has finished. The course is described as a toolbox containing different tools known to be useful in reducing depression. The tools are relaxation techniques, pleasant activities, assertiveness skills and constructive thinking. The course is based on the social-learning theory of depression in which the lack of enjoyment, the inertia and the negative expectations about feeling better prevent the depressed person to seek pleasant activities. Methods known from cognitive-behavior therapy such as homework assignments are also used to bring about the improvements changes. The group size varies between six and ten participants and usually two course trainers are attached to the course.
Participants, who do not need a referral, are recruited by advertising in the local media, and senior journals. The treatment department of the CMHCs are also notified of the start of the next course. This recruitment strategy results in very heterogeneous groups with participants who suffer from an acute MDD as well as persons with hardly any depression symptoms during the course. At the intake interview, carried out by the group leader who is usually a psychologist, the following topics are discussed:
demographics (age, civil state, children, and income), life events like recent bereavement, health, and depression-related symptoms, current and in the past. A self- report questionnaire such as the CES-D (Radloff, 1977) or the Geriatric Depression
General Introduction
17 Scale (GDS; Yesavage, 1983) is used to assess the current level of depression.
Furthermore, the course itself, its goals and what is expected from the participant (home work) are brought up. The suitability of the course is then discussed. Reasons for exclusion are severe depression, current bipolar disorder, schizophrenia, acute substance disorder, cognitive impairment, recent bereavement, hearing impairment, and insufficient command of the Dutch language.
4. Outline
This study was designed to answer two major questions about the CWD course in the reality of the Dutch mental health care system. First, how effective is the course?
Second, is the course more effective for some than for others? Moreover, we analyzed the criterion validity of the depression questionnaire CES-D and studied the autobiographical memory as a marker of cognitive vulnerability for depression.
In chapter 1, the criterion validity of the main outcome measure, CES-D (Radloff, 1977) was analyzed. The purpose was to determine the optimal cut-off point of the CES-D to identify individuals with either a major depressive disorder or with a clinically relevant depression. Furthermore, we analyzed to what extent sociodemographic characteristics, physical health, medication use, high anxiety levels, comorbid axis I disorders and previous depressive episodes predicted true and false positives.
In chapter 2, the immediate effectiveness of the course was studied using a randomised, controlled design. The control condition was a waiting list of the same duration as the course. For ethical reasons they were not kept waiting until the intervention group had completed the follow-up. Hence, the long term effectiveness of the course was studied in a naturalistic follow-up of 14 months. The data of the participants from the intervention group combined with those on the waiting list who had completed the course were used.
In chapter 3 we examined a wide variety of demographic, clinical, psychosocial and treatment factors of possible relevance for selective and indicated prevention at short- and long-term. Knowledge of prognostic factors can be helpful to provide matched care, which in turn can result in a higher level of treatment outcome.
In chapter 4, we shall describe an experiment that was conducted with participants who had finished the course and had indicated feeling only slightly depressed and a control group of elders who had never been depressed. This research was designed to study: (a) whether autobiographical memory specificity (AMS) in the two groups differed, and (b) if AMS had predictive validity in the course participants for the level of depression at follow- up.
18
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Arean, P. A. & Cook, B. L. (2002). Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression. Biological Psychiatry, 52, 293-303.
Baldwin, R. C., Anderson, D., Black, S., Evans, S., Jones, R., Wilson, K. et al.
(2003). Guideline for the management of late-life depression in primary care.
International of Geriatric Psychiatry, 18, 829-838.
Bartels, S. J., Oxman, M. N., Schneider, L. S., Arean, P. A., Alexopoulos, G. S.,
& Jeste, D. V. (2002). Evidence-based practices in geriatric mental health care. Psychiatric Services, 53, 1419-1431.
Beck A.T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives General Psychiatry, 4, 561- 571.
Beekman, A.T.F., Deeg, D.J.H., Tilburg, T. van, Smit, J.H., & Hooijer, C. (1995).
Major and minor depression in later life: A study of prevalence and risk factors. Journal of Affective Disorders, 36, 65-75.
Beekman, A.T.F., Deeg, D. J. H., Braam, A. W., Smit, J. H., & Tilburg, W. van (1997). Consequences of major and minor depression in later life: a study of disability, well-being and service utilization. Psychological Medicine, 27, 1397-1409.
Beekman A.T.F., Deeg D.J.H., Braam A, & Vries, M.Z. de (1997a). Criterion validity of the Center for Epidemiologic Studies Depression scale (CES-D):
Results from a community-based sample of older subjects in the Netherlands.
Psychological Medicine, 27, 231-235.
Beekman, A.T.F., Penninx, B.H., Deeg, D.J.H., Ormel, J., Braam, A.W., &
Tilburg, W. van (1997). Depression and physical health in later life: results from the Longitudinal Aging Study Amsterdam (LASA). Journal of Affective Disorders, 46, 219-231.
Beekman, A.T.F., Copeland, J.M., & Prince, M. J. (1999). Review of community prevalence of depression in later life. British Journal of Psychiatry, 174, 307- 311.
Blazer, D. G., Hughes, D. C., & George, L. K. (1987). The epidemiology of depression in an elderly community population. The Gerontologist, 27, 281- 287.
Blazer, D. G., Kessler, R. C., Mcgonagle, K. A., & Swartz, M. S. (1994). The prevalence and distribution of major depression in a national community sample - the National Comorbidity Survey. American Journal of Psychiatry, 151, 979-986.
General Introduction
19 Bristow, K. & Patten, S. (2002). Treatment-Seeking rates and associated
mediating factors among individuals with depression. Canadian Journal of Psychiatry, 47, 660-665.
Brittlebank, A. D., Scott, J., Williams, J. M., & Ferrier, I. N. (1993).
Autobiographical Memory in depression: state or trait marker? British Journal of Psychiatry, 162, 118-121.
Burke, K. C., Burke, J. D., Regier, D. A., & Rae, D. S. (2006). Age at onset of selected mental disorders in five community populations. Archives General Psychiatry, 47, 511-518.
Central Bureau Statistics (2007). Kerncijfers van de bevolkingsprognose 2004 - 2050, Prognose.
Cole, M. G. & Dendukuri, N. (2003). Risk factors for depression among elderly community subjects: a systematic review and meta-analysis. American Journal of Psychiatry, 160, 1147-1156.
Coryell, W., Winokur, G., Shea, T., Maser, J. D., Endicott, J., & Akiskal, H. S.
(1994). The long-term stability of depressive subtypes. American Journal of Psychiatry, 151, 199-204.
Cuijpers, P. (1998). Psychological outreach programmes for the depressed elderly: a meta-analysis of effects and dropout. International Journal of Geriatric Psychiatry, 13, 41-48.
Engels, G. I. & Vermey, M. (1997). Efficacy of nonmedical treatments of depression in elders; a quantitave analysis. Journal of Clinical Gerontology, 3, 17-35.
Ernst, C. (1997). Epidemiology of depression in late life [Mood Disorders].
Current Opinion in Psychiatry, 10, 107-112.
Feil, D., Razani, J., Boone, K., & Lesser, I. (2003). Apathy and cognitive performance in older adults with depression. International Journal of Geriatric Psychiatry, 18, 479-485.
Feldman, E. L., Robbins, A., & Jaffe, A. (1998). Selections from current literature: minor depression. Family Practice, 15, 275-281.
Frasure-Smith, N. & Lesperance, F. (2006). Recent evidence linking coronary heart disease and depression. Canadian Journal of Psychiatry 51, 730-737.
Friedman, M. A., Detweiler-Bedell, J. B., Leventhal, H. E., Home, R., Keitner, G.
I., & Miller, I. W. (2004). combined psychotherapy and pharmacotherapy for the treatment of Major Depressive Disorder. Clinical Psychology: Science and Practice, 11, 47-68.
Geiselmann, B. & Bauer, M. (2000). Subthreshold depression in the elderly:
Qualitative or quantitative distinction? Comprehensive Psychiatry, 41[2 (S1)], 32-38.
Gildengers, A. G., Houck, P. R., Mulsant, B. H., Pollock, B. G., Mazumdar, S., Miller, M. D. et al. (2002). Course and rate of antidepressant response in the very old. Journal of Affective Disorders, 69, 177-184.
20
Hamilton, M. (1967). Development of a rating scale for primary depressive illness. British Journal of Social and Clinical Psychology, 6, 278-296.
Heun, R., Kockler, M., & Papassotiropoulos, A. (2000). Distinction of early- and late-onset depression in the elderly by their lifetime symptomatology.
International Journal of Geriatric Psychiatry, 15, 1138-1142.
Janssen, J., Beekman, A.T.F., Comijs, H. C., Deeg, D. J. H., & Heeren, T. J.
(2006). Late-life depression: the differences between early- and late-onset illness in a community-based sample. International Journal of Geriatric Psychiatry, 21, 86-93.
Judd, L. L., Akiskal, H. S., Maser, J. D., Zeller, P. J., Endicott, J., Coryell, W. et al. (1998). A prospective 12-year study of subsyndromal and syndromal depressive symptoms in unipolar Major Depressive Disorders. Archives of General Psychiatry, 55, 694-700.
Karel, M. J. & Hinrichsen, G. (2000). Treatment of depression in late life:
psychotherapeutic interventions. Clinical Psychology Review, 20, 707-729.
Kessing L.V., Hansen M.G., Andersen P.K., & Angst, J. (2004). The predictive effect of episodes on the risk of recurrence in depressive and bipolar disorders - a life-long perspective. Acta Psychiatrica Scandinavica, 109, 339- 344.
Kessler, R. C. (1997). The effects of stressful life events on depression. Annual Review of Psychology, 48, 191-214.
Kruijshaar, M. E., Barendregt, J., Vos, T., de Graaf, R., Spijker, J., & Andrews, G. (2005). Lifetime prevalence estimates of major depression: An indirect estimation method and a quantification of recall bias. European Journal of Epidemiology, 20, 103-111.
Lewinsohn, P. M. & Clarke, G. N. (1984). Group treatment of depressed individuals: The "Coping with Depression" course. Advances in Behaviour Research and Therapy, 6, 99-114.
Mackinger, H. F., Pachinger, M. M., Leibetseder, M. M., & Fartacek, R. R.
(2000). Autobiographical memories in women remitted from major depression. Journal of Abnormal Psychology, 109, 331-334.
Marin, R. S., Butters, M. A., Mulsant, B. H., Pollock, B. G., & Reynolds, C. F., III (2003). Apathy and executive function in depressed elderly. Journal of Geriatric Psychiatry and Neurology, 16, 112-116.
McCusker, J., Cole, M., Keller, E., Bellavance, F., & Berard, A. (1998).
Effectiveness of treatments of depression in older ambulatory patients.
Archives of Internal Medicine, 158, 705.
Mitchell, A. J. & Subramaniam, H. (2005). Prognosis of depression in old age compared to middle age: a systematic review of comparative studies.
American Journal of Psychiatry, 162, 1588-1601.
Mrazek, P. J. & Haggerty, R. J. (1994). New directions in definitions. In P.J.Mrazek & R. J. Haggerty (Eds.), Reducing risks for mental disorders:
General Introduction
21 Frontiers for preventive intervention research (pp. 19-29). Washington:
National Academy Press.
Mueller, T. I., Leon, A. C., Keller, M. B., Solomon, D. A., Endicott, J., Coryell, W. et al. (1999). Recurrence after recovery from Major Depressive Disorder during 15 years of observational follow-up. American Journal of Psychiatry, 156, 1000-1006.
Murata T, Kimura, H., Omori, M., Kado, H., Kosaka, H., Idaka, T., et al. (2001).
MRI white matter hyperintensities, H-1-MR spectroscopy and cognitive function in geriatric depression: a comparison of early- and late-onset cases.
International Journal of Geriatric Psychiatry, 16, 1129-1135.
Nandrino, J. L., Pezard, L., Poste, A., Reveillere, C., & Beaune, D. (2002).
Autobiographical memory in major depression: A comparison between first- episode and recurrent patients. Psychopathology, 35, 335-340.
Ojen, R.van, Hooijer, C., Jonker, C., Lindeboom, J., & Tilburg, W. van (1995).
Late-life depressive disorder in the community, early onset and the decrease of vulnerability with increasing age. Journal of Affective Disorders, 33, 159- 166.
Onyike, C. U. M., Sheppard, J. M., Tschanz, J. T. P., Norton, M. C. P., Green, R.
C. M., Steinberg, M. M. D. et al. (2007). Epidemiology of apathy in older adults: the Cache County Study. American Journal of Geriatric Psychiatry, 15, 365-375.
Ormel, J., Kempen, G. I., Deeg, D. J., Brilman, E. I., Sonderen, E. van, &
Relyveld, J. (1998). Functioning, well-being, and health perception in late middle-aged and older people: comparing the effects of depressive symptoms and chronic medical conditions. Journal of The American Geriatrics Society, 46, 39-48.
Park, R. J., Goodyer, I. M., & Teasdale, J. D. (2002). Categoric overgeneral autobiographical memory in adolescents with major depressive disorder.
Psychological Medicine, 32, 267-276.
Pincus, H. A., Davis, W. W., & McQueen, L. E. (1999). 'Subthreshold' mental disorders. A review and synthesis of studies on minor depression and 'brand names'. British Journal of Psychiatry, 174, 288-296.
Radloff, L. S. (1977). The CES-D Scale: a self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401.
Roose, S. P., Sackeim, H. A., Krishnan, K. R. R., Pollock, B. G., Alexopoulos, G., Lavretsky, H. et al. (2004). Antidepressant pharmacotherapy in the treatment of depression in the very old: a randomized, placebo-controlled trial. American Journal of Psychiatry, 161, 2050-2059.
Rothermund, K. & Brandtstadter, J. (2003). Depression in later life: cross- sequential patterns and possible determinants. Psychology and Aging, 18, 80- 90.
22
Schoevers, R. A., Beekman, A.T.F., Deeg, D. J. H., Geerlings, M. I., Jonker, C.,
& Tilburg, W. van (2000). Risk factors for depression in later life; results of a prospective community based study (AMSTEL). Journal of Affective Disorders, 59, 127-137.
Schoevers, R. A., Beekman, A.T.F., Deeg, D. J. H., Hooijer, C., Jonker, C., &
Tilburg, W. van (2003). The natural history of late-life depression: results from the Amsterdam Study of the Elderly (AMSTEL). Journal of Affective Disorders, 76, 5-14.
Spinhoven, Ph., Bockting, C. L. H., Schene, A. H., Koeter, M. W. J., Wekking, E.
M., & Williams, J. M. (2006). Autobiographical memory in the euthymic phase of recurrent depression. Journal of Abnormal Psychology, 115, 590- 600.
Stek, M. L., Gussekloo, J., Beekman, A.T.F., Tilburg, W. van, & Westendorp, R.
G. J. (2004). Prevalence, correlates and recognition of depression in the oldest old: the Leiden 85-plus study. Journal of Affective Disorders, 78, 193- 200.
Stek, M. L., Vinkers, D. J., Gussekloo, J., Mast, R. C. van der, Beekman, A.T.F.,
& Westendorp, R. G. J. (2006). Natural history of depression in the oldest old - Population-based prospective study. British Journal of Psychiatry, 188, 65- 69.
Tulving, E. (2002). Episodic memory: From mind to brain. Annual Review of Psychology, 53, 1-25.
Vreeswijk, M. F. van & Wilde, E. J. de (2004). Autobiographical memory specificity, psychopathology, depressed mood and the use of the Autobiographical Memory Test: a meta-analysis. Behaviour Research and Therapy, 42, 731-743.
Vinkers, D. J., Stek, M. L., Mast, R. C. van der, Craen, A. J. M. de, Le Cessie, S., Jolles, J. et al. (2005). Generalized atherosclerosis, cognitive decline, and depressive symptoms in old age. Neurology, 65, 107-112.
Vinkers, D. J., Mast, R.C. van der, Stek, M. L., Westendorp, & Gussekloo, J.
(2006). De relatie tussen atherosclerose, cognitieve achteruitgang en depressie bij ouderen. [The relationship between atherosclerosis, cognitive impairment, and depression in old age]. Nederlands Tijdschrift voor Geneeskunde, 150, 2307-2311.
Weissman, M. M. & Olfson, M. (1995). Depression in women - implications for health-care research. Science, 269, 799-801.
Wells, K. B., Stewart, A., Hays, R. D., Burnam, M. A., Rogers, W., Daniels, M.
et al. (1989). The functioning and well-being of depressed patients - Results from the Medical Outcomes Study. JAMA-Journal of the American Medical Association, 262, 914-919.
Williams, J. M. G. & Broadbent, K. (1986). Autobiographical memory in suicide attempters. Journal of Abnormal Psychology, 95, 144-149.
General Introduction
23 Williams, J. M. G. (1996). Depression and the specificity of autobiographical
memory. In D.C.Rubin (Ed.), Remembering our past. Studies in autobiographical memory (pp. 244-267). Cambridge: University Press.
Wilson, K., Mottram, P., Sivanranthan, A., & Nightingale, A. (2001).
Antidepressants versus placebo for the depressed elderly (review). Cochrane Database of Systematic Reviews 2001 [1].
Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M. et al.
(1983). Development and validation of a geriatric depression screening scale:
A preliminary report. Journal of Psychiatric Research, 17, 37-49.
2
The criterion validity of the Center for
Epidemiological Studies Depression Scale (CES-D) in a sample of self-referred elders with depressive
symptomatology
Haringsma, R. , Engels, G.I., Beekman, A.T.F., & Spinhoven, Ph. (2004). The criterion validity of the Center for Epidemiological Studies Depression Scale (CES-D) in a sample of self-referred elders with depressive symptomatology. International Journal of Geriatric Psychiatry, 19: 558-563.
26
Abstract
Background
The criterion validity of the Center for Epidemiological Studies Depression scale (CES-D) was assessed in a group of elderly Dutch community-residents who were self-referred to a prevention program for depression.
Methods
Paper-and-pencil administration of the CES-D to 318 elders (55-85 years). Criterion validity was evaluated with the Mini International Neuropsychiatric Interview (M.I.N.I.), a clinical diagnostic interview based on DSM-IV. Sensitivity and specificity for various cut-off scores of CES-D were compared with the DSM-IV major depressive disorder (MDD) and with clinically relevant depression (CRD), a composite diagnosis of MDD, subthreshold depression or dysthymia. Furthermore, the characteristics of true versus false positives were analyzed.
Results
For MDD, the optimal cut-off score was 25, (sensitivity 85%, specificity 64%, and positive predicted value of 63%). For CRD, the optimal cut-off was 22 (sensitivity 84%, specificity 60%, and positive predicted value 77%). True positives, MDD and CRD, reported significantly more anxiety symptomatology and more co-morbid anxiety disorders, false positives reported more previous depressive episodes.
Conclusions
The criterion validity of the CES-D for MDD and CRD was satisfactory in this semi- clinical sample of elders. Subjects scoring ≥ 25 constitute a target group for further diagnostic assessment in order to determine appropriate treatment.
Criterion validity CES-D
27
Introduction
Prevention of depression in the elderly has become a priority in Community Mental Health Care. For this purpose, ‘outreach programs’ have been developed (Cuijpers, 1998b; Cuijpers et al., 1995; Lewinsohn et al., 1984). Participants are recruited through announcements in the local media. Open recruitment probably attracts participants with a high base rate of depressive complaints, a history of previous depressive episodes, high levels of anxiety and co-morbid psychiatric disorders. This calls for a two stage screening procedure with a valid instrument like the Center for Epidemiological Studies Depression scale (CES-D) (Radloff, 1977). The CES-D is recommended to assess depressive symptomatology in the elderly (Beekman et al., 1994; Himmelfarb and Murrell, 1983; Lewinsohn et al., 1997; Radloff & Teri, 1986), but has not been investigated as yet for this target group.
Beekman et al. (1997a) studied the criterion validity of the CES-D in a community sample of Dutch elders; they advised to use ≥ 16 as cut-off. In clinical settings however, this cut-off yielded high false-positive rates. Depending on the setting, recommended cut scores varied from 20 to 27 (Himmelfarb and Murrell, 1983;
Schulberg et al., 1985; Zich et al., 1990). Himmelfarb and Murrell (1983) used the CES-D to discriminate between a community sample and a clinical sample of elders;
they recommended 20 as cut-off score.
In this study, the criterion validity of the CES-D was examined in a group of elderly community residents, self-referred to an outreach program for secondary prevention of depression provided by Dutch Community Mental Health Care Centers.
In the elderly milder forms of depression are more prevalent than major depressive disorder (MDD), however they cause as much suffering (Beekman et al., 1995; Hybels et al., 2001; Lewinsohn et al., 2000). Therefore the power of the CES-D to screen for all the disorders in the depressive spectrum is also studied: major depressive disorder (MDD); subthreshold depression (SD) and dysthymia, taken together as clinically relevant depression (CRD).
Following Beekman et al. (1997a), we also studied the characteristics of true and false positives. They found that higher levels of anxiety symptoms were characteristic for true positives, but sociodemographic characteristics, medication and physical health did not predict classification. In addition to these variables, the predictive value of co-morbid anxiety disorders and the presence of previous depressive episodes will be studied here.
Method
Sampling and Procedures
This study was part of a field-study into the effectiveness of the Coping-with- Depression Course for elders (Cuijpers, 1998a; Lewinsohn et al., 1984). The program aims at secondary prevention of mild depressive symptoms and is provided by 60% of the prevention departments of Community Mental Health Care Centers (CMHCC) in
28
the Netherlands. Using active recruitment methods, participants were recruited and accepted by the CMHCCs. Eligible for this study were all the participants aged 55 and older. The study was approved by the Medical Ethics Committee of the Leiden University Medical Centre. All subjects signed an informed consent. After joining the study, a booklet with baseline questionnaires was distributed to be completed at home.
Within two weeks diagnostics by the researchers took place. The Mini International Neuropsychiatric Interview (M.I.N.I; Overbeek et al., 1999; Sheehan et al., 1997, 1998) was used. All baseline questionnaires were checked for missing items and incorrect responses. These were discussed with the participant and remediated.
Measures
The M.I.N.I. (Sheehan et al., 1998) assesses the most prevalent axis 1 disorders according to the diagnostic and statistical manual of mental disorders (DSM-IV;
American Psychiatric Association, 1994). Diagnoses are based on the dimensional scores obtained. Current MDD (score 5-9), subthreshold depression (SD, score 2-4), and dysthymia were used as criteria. These three diagnoses were combined into the diagnosis ‘Clinically Relevant Depression (CRD)’. Interviews were conducted by trained interviewers at the CMHCCs; interrater reliabilities were .94 (MDD), .87 (SD), and 1.0 (Dysthymia).
Anxiety symptomatology was measured with the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A) (Zigmond & Snaith,1983). The recommended cut-off of 8 was used as demarcation between high and low anxiety levels. Physical health was assessed with the scales for pain and physical functioning of the Medical Outcome Study Short Form General Health Survey (MOS-SF-20) (Kempen, 1992; Stewart et al., 1988), and with a checklist with chronic medical conditions Central Bureau for Statistics (CBS, 1989).
Statistics
The Statistical Package for Social Sciences (SPSS) 11.1 was used. Using Receiver Operating Characteristics (ROC), the association between CES-D scores and the different clinical diagnoses (MDD and CRD) was studied. χ2 analyses and logistic regression analyses were used to compare characteristics of false and true positives.
Results
The mean age of the 318 participants was 65.5 years (SD = 7.2), range 55-85.
Participants were predominantly female, frequently living alone, and educated to low or middle levels (see Table 1). The mean sum score on the CES-D was 25.9 (SD = 9.7); 85% had a sum score ≥ 16. The mean score on the HADS anxiety scale was 10.2 (SD = 4.2); 75% had a score ≥ 8.
Criterion validity CES-D
29 Table 1. Sample Characteristics (N = 318)
Variable N = 318 (%) Mean (SD)
Age 55 – 85 55-64 65-74 75-85
160 110 48
(50.3%) (34.6%) (15.1%)
65.5 (7.2)
Sex
Female 231 (72.6%)
Living situationa
Alone 150 (47.3%)
Level education a Low
Middle High
104 127 84
(33.0%) (40.3%) (26.7%) Medication use: b
Antidepressants and/or sedatives# 167 (52.7%) CES-D sum score
≥ 16
≥ 22
≥ 25
269 213 179
(84.3%) (67.0%) (56.3%)
25.86 (9.74)
HADS anxiety score
≥8 238 (74.8%)
10.23 (4.21) MOS-SF 20
MOS-pain
MOS physical funct c
45.91 33.27) 54.96 (33.2) Chronic diseases (nbr) d
None One
More than one
96 106 105
(31.3%) (34.5%) (33.2%) Axis I Disorders:
No axis 1 disorder Axis 1, but not CRD CRD
82 40 196
(25.8%) (12.6%) (61.6%) Depressive disorders CRD:
MDD SD Dysthymia Anxiety disorders
CRD with co-morbid anxiety disorder
133 37 26 133 97
(41.8%) (11.6%) (8.2%) (41.8%) (30.5%) MDD history
Never MDD, MDD in remission
45 140
(14.2%) (44.0%)
a 3 missing observations ; b 1 missing observation; c 2 missing observations; d 11 missing observations; # includes St John’s Worth; CES-D = Center of Epidemiological Studies–
Depression scale; HADS = Hospital Anxiety and Depression Scale; MOS-SF 20 = Medical Outcome Study Short Form General Health Survey; CRD = Clinically Relevant Depression.
CRD can be either MDD or SD or Dysthymia; MDD = Major Depressive Disorder; SD = Subthreshold Depression.
Table 2. AUC, Sensitivity, Specificity and Positive Predicted Value (PPV) of the CES-D for different cut-off and different combinations of depressive disorders
CES-D CES-D CES-D CES-D CES-D
Disorder ≥≥≥≥ 16 ≥≥≥≥18 ≥≥≥≥20 ≥≥≥≥22 ≥≥≥≥25
AUC Sens Spec PPV Sens Spec PPV Sens Spec PPV Sens Spec PPV Sens Spec PPV MDDa .833 96.2 23.8 47.6 94.7 31.9 50 93.2 43.2 54.1 91 50.3 56.8 85 64.3 63.1 MDD+SDb .801 95.3 27.7 60.2 94.1 37.8 63.5 90 48.6 66.8 87.1 56.1 69.5 77.1 67.6 73.2 MDD+Dysthym .800 93.1 23.9 55 90.6 32.1 57.1 88.1 44 61.1 86.2 52.2 64.3 78.6 66 69.8 CRDc .79 92.9 28.7 67.7 90.8 39.3 70.6 86.2 50.8 73.8 83.7 59.8 77 73 70.5 79.9
a MDD=Major Depressive Disorder; b SD = Subthreshold depression; c CRD= Clinically Relevant Depression. CRD can be either MDD or SD or Dysthymia.
Criterion validity CES-D
31 Table 3. Characteristics of True and False positives for MDD and CRD
MDD cut off 25 n = 179 CRD cut off 22, n = 213 True pos
n = 113
False pos n =66
True pos n =164
False pos n =49 HADS anxiety scale
≥ 8 91% 76% 89% 78%
Anxiety disorders 56% 32% 51% 31%
Previous depressive episodes 54% 80% 62% 86%
The area under the curve (AUC) found with ROC analyses was 0.83 for MDD [SE = 0.02; 95% Confidence Intervals (CI) 0.79 - 0.88; p < 0.001] and 0.79 for CRD (SE = 0.3; CI 0.74 – 0.84; p < 0.001). Specificity, sensitivity and positive predicted values (PPV) were calculated using the cut scores 16, 18, 20, 22, 24, 25 and 26 (see Table 2). With MDD as the criterion, the cut score 25 showed optimal balance between sensitivity (85%) and specificity (64%), PPV 63%. For CRD, 22 was a better cut-off, with a sensitivity of 84%, specificity of 60% and PPV 77%.
Using the cut-off ≥ 25 as indication for MDD, the sample had 113 true positives (TPs) and 66 false positives (FPs). TP or FP showed no relationship with demographic characteristics, medication or physical health variables. However, TPs scored significantly higher on the HADS-A than FPs, t(177, n =179) = -4.4; p < 0.001.
Also significant was the association with anxiety disorders, χ2(1, n =179) = 8.6, (p <
0.01), and with previous depressive episodes, χ2(1, n =179) = 11.4, p = 0.001. Anxiety disorders were predominant in TPs, whereas previous depressive episodes were highest in FPs. Direct logistic regression with anxiety, co-morbid anxiety disorders and previous depressive episodes as predictors was statistically reliable, χ2(3, n = 179)
= 39.8, p < 0.001. Controlling for confounding, anxiety [Odds Ratio (OR)1.2], co- morbid anxiety disorders (OR 2.3) and previous depressive episodes (OR .21) reliably distinguished between TPs and FPs.
Using the cut-off ≥ 22 as an indication for the presence of CRD, the sample counted 164 TPs and 49 FPs. A similar pattern emerged. First, no relationship was found with demographic characteristics, medication or the physical health variables.
Second, TPs scored significantly higher than FPs on the HADS the anxiety scale, t (211, n = 213) = -4.9; p < 0.001.Third, significant associations were found with anxiety disorders, χ2(1, n = 213) = 5.6, p < 0.05 and with previous depressive episodes, χ2(1, n =213) = 8.9, p < 0.01. Anxiety disorders were more prevalent in TPs than in FP, whereas FPs had a higher proportion of previous depressive episodes. Direct logistic regression analysis with anxiety, co-morbid anxiety disorders and previous depressive episodes as predictors was statistically reliable, χ2(3, n = 213) = 39.95, p <
0.001. When controlling for confounding factors, anxiety (OR 1.3), and previous depressive episodes (OR .19) reliably distinguished between TPs and FPs. However,
32
the unique contribution of co-morbidity became statistically borderline significant.
Table 3 summarizes the characteristics of TPs and FPs.
Discussion
Sociodemographic characteristics, physical and mental health status show that the elders in this study represent a vulnerable group in the community. They resembled a sample of psychiatric outpatients more than a community sample. Clinical diagnosis showed that the vast majority had a lifetime DSM-IV-diagnosis for MDD and that 42% met the criteria for a current MDD. The mean CES-D score was 25.9, a figure similar to that reported by Radloff (1977) for her psychiatric sample. SD (12%) and dysthymia (8%) were much less prevalent. However, co-morbid anxiety disorders were widely prevalent (30.5%)
In our sample with its high rate of psychiatric disorders, the CES-D is moderately accurate (Greiner, Pfeiffer and Smith, 2000) in detecting MDD. The optimal cut-off for the CES-D lies higher than in a community sample. The optimal cut scores of 25 for MDD and 22 for CRD are similar to those found in studies of clinical samples (Himmelfarb & Murrell, 1983; Schulberg et al., 1985; Zich et al., 1990). Studies in which the HADS or Geriatric Depression Scale (GDS) were used in psychiatric settings corroborate our findings: reported sensitivities were good, while the specificities were low (Silverstone, 1994 and Chattat et al., 2001).
Despite these higher cut scores the proportion of false positives (FP) was still substantial. TPs and FPs did not differ with regard to sociodemographic characteristics or physical health variables. This is consistent with other studies where no direct association was found between physical illness and MDD (Beekmann et al., 1997b;
Williamson & Schulz, 1992; Zeiss et al., 1996).
However, TPs and FPs did differ in mental health status. In the TPs high levels of anxiety and co-morbid anxiety disorders were more prevalent than in the FPs. This is in line with the study results of Beekman et al., (1997a; 2000), Flint, (1994) and Schoevers et al., (2003). The FPs were characterized by more previous depressive episodes than TPs. This suggests that a high CES-D score, combined with a previous history of depression, falsely points to a current depressed state. However, such a score might indicate that either a new depression is developing or that the last depression is not completely in remission.
In our opinion, subjects scoring ≥ 25 on the CES-D should be followed up with a diagnostic interview to specify clinical diagnosis and appropriate treatment. In this group 63% will have a MDD and therefore should be treated in a curative program rather than a prevention program. The CES-D can also be used as an outcome measure, since it measures the current level of symptomatology and is sensitive to changes over time (Radloff, 1977; Radloff and Teri, 1986). In an outtake procedure a score ≥ 25 may indicate that more care is needed.
A feature of this study that might have an effect on the scores is the paper-and pencil mode of administration of the CES-D. Geerlings et al., (1999) found that scores
